As of March 19, India believes that the coronavirus is still an entirely imported infection. According to the authorities, it is not yet circulating in the general population. With this in mind, India’s Health Ministry has created a set of exacting standard operating procedures to be adhered to at international airports to ensure that potential cases are tracked.

Anyone with a fever or coming from a heavily coronavirus-affected country – including China, South Korea, Italy, France and others – is supposed to be immediately isolated and quarantined in a government facility for 14 days.

But with the disease having spread to more than 100 countries now, the guidelines also require many passengers who are not showing symptoms to go to home quarantine. This involves the individuals following another set of guidelines about how they should be isolated at home.

But home is often far away from the airport. And people don’t always understand or follow the quarantine rules.

With tens of thousands of people around the country in this situation (the Times of India said 70,000 were under home quarantine in Hyderabad alone), what do these challenges pose for India’s fight against the virus?

Where is home?

On Wednesday, for example, four engineering students who had just returned from Germany and were returning to their homes in Gujarat had to be taken off a train in Palghar, just outside Mumbai, after other passengers raised concerns about sharing a cabin with them.

According to the Times of India, the four had cleared the thermal screening at the airport – meaning they did not show symptoms – but were told to go to home quarantine. Maharashtra has begun using indelible ink to stamp the hands of those recommended for home quarantine, a measure that other states are planning to take up as well.

The four students were stamped and told to wear masks and use sanitisers and to return to their homes. So they boarded the train. But when other passengers found out, “they started hurling insults at them for ‘putting others at risk’,” according to the report. Eventually, the students were taken off the train, checked at a local hospital and then had to hire a large car to take them home by road.

The students were following directions given to them but others on the train felt unsafe. What was the right thing to do?

“There is a big difference between irresponsibility – someone who knowingly breaks the rules – and certain kinds of behaviour that is because of vulnerability,” said Vandana Prasad, Founder Secretary, National Convenor and Technical Advisor for Public Health Resource Network.

She noted that people need to be given support and guidance about correct behaviour and that everyone, whether they are neighbours or co-passengers on a train, need to be compassionate about each person’s vulnerabilities.

On the train for example, Prasad said that if the students were wearing masks, others needed to simply make sure they follow the guidelines – maintain distance and wash hands with soap or use sanitiser – instead of getting angry with them.

“There is a big concern that people are going to be left without support,” Prasad said. “That they can’t get home, and the places that they’re staying in – hostels, lodges – are closing down. That’s very unfair and in that case, institutions need to take care of them. Otherwise, this is the worst-case scenario – institutions are shutting down, yet travel restrictions might come in preventing these people from going home. We need policies that are compassionate.”

In many places in China, for example, international travelers will be immediately moved to “quarantine hotels”, instead of being sent to home quarantine – an effort to reduce the chances of spreading the disease. Delhi is the only Indian city that offers this option, and at the moment it requires travelers to pay Rs 3,000 per night.

The scene at Mumbai's Kasturba Hospital. Credit: PTI

Enforcing quarantine

Homes that aren’t in the same city as the airport aren’t the only challenges facing India’s home quarantine policy as the government attempts to tackle the massive crisis that is coronavirus.

In several cases, individuals – such as an Indian Police Service officer in Patna or a bureaucrat in West Bengal – have slipped through gaps in the disease surveillance process, claiming that they were not given strict instructions or entered the country before the rules were changed.

In Pimpri-Chinchwad, near Pune in Maharashtra, municipal corporations have had to appoint squads “to visit the homes of quarantined folks in different parts of the city to ensure they were adhering to the isolation mandated”.

Mumbai’s municipal corporation has gone a step further: It has now asked Mumbai Police to track the movements of those who are required to do mandatory home quarantine through GPS location on their phones.

The government is now considering stamping all passengers from abroad with a “home quarantine” mark – which includes the date until which they are supposed to stay isolated – no matter where they come from.

“With so many people resisting quarantine, the government is looking into hand stamping and fining people to enforce home quarantine,” Dr Randeep Guleria, director, All India Institute of Medical Sciences told the Hindustan Times. “People should be more socially responsible, but with so many cases of people running away and breaking quarantine, we have to find ways to ensure compliance to protect the community from infection.”

Can quarantine work?

The Ministry’s home quarantine guidelines attempt to adjust for Indian conditions, but they are likely to prove difficult to follow for many people, especially if the virus goes beyond the affluent who make up the bulk of international travelers.

The home quarantined person should:

  • Stay in a well-ventilated single-room preferably with an attached/separate toilet. If another family member needs to stay in the same room, it’s advisable to maintain a distance of at least 1 meter between the two.
  • Needs to stay away from elderly people, pregnant women, children and persons with co-morbidities within the household.
  • Wash hands as often thoroughly with soap and water or with alcohol-based hand sanitizer
  • Avoid sharing household items e.g. dishes, drinking glasses, cups, eating utensils, towels, bedding, or other items with other people at home.
  • Wear a surgical mask at all the time. The mask should be changed every 6-8 hours and disposed off. Disposable masks are never to be reused.
  • Clean and disinfect frequently touched surfaces in the quarantined person’s room (e.g. bed frames, tables etc.) daily with 1% Sodium Hypochlorite Solution.
  • Clean and disinfect toilet surfaces daily with regular household bleach solution/phenolic disinfectants.

Data shows that 40% of India’s population does not have basic hand-washing facilities, including soap and water. In many of the country’s poorer areas, maintaining distance between a potentially infected individual, not sharing household items and replacing surgical masks every 6-8 hours may simply not be possible.

“This doesn’t mean we shouldn’t have technical guidelines,” said Prasad, of the Public Health Resource Network. “We must know what is correct and then see how to adapt to circumstances. We might say that the guidelines don’t account for those who don’t have water, but... there is a lot that can be done to make up for the gap between the advisories and the circumstances.”

The fear is that the responses from people over the next two or three weeks, which health officials say are critical, will be individualistic rather than community based. People are already panic buying, leading to food shortages. One video shows a man being beaten up for sneezing in public. An elderly couple, who were carrying out self-isolation in Kerala, were locked in by their housing association – eventually leading to four arrests.

“We are going to need a lot more understanding and support rather than pointing fingers and victim blaming,” Prasad said. “Things are only going to get tougher, and as supplies dry out, this situation can get very nasty unless we engage in a process where communities start to take care of each other. This is not the time to be selfish or to wield a rule book.”